Ger. neurologist, 1864-1915.
Stages of Alzheimer Disease
|Stage I (early stage, mild dementia)||Loss of short-term memory|
|Decreased judgment (safety concern)|
|Inability to perform mathematical calculations|
|Inability to comprehend abstract ideas|
|Stage II (middle stage, moderate dementia)||Difficulty with speech and language (aphasia, anomia)|
|Labile personality changes|
|Changes in usual grooming habits|
|Inability to remember purpose of items (apraxia)|
|Psychotic behaviors, such as hallucinations and paranoia|
|Stage III (late stage, severe dementia)||Inability to perform activities of daily living, such as eating, dressing, and bathing; requires total care|
|Inability to walk, toilet, swallow|
|Minimal or no communication|
|Eventually becomes bedridden and develops complications of immobility, such as pneumonia, pressure ulcers, and constipation|
ABBR: AD A chronic, progressive, degenerative cognitive disorder that causes deterioration in thinking and everyday functioning among older adults. The diseases costs $80 to $100 billion for health care and lost wages in the U.S. annually. The number of patients is expected to more than triple in the next 30 years (14 million by 2050) as more people live into their 80s and 90s.
SYN: SEE: senile dementia of the Alzheimer type
SEE: positron emission tomography for illus
It is the most common form of dementia in mature adults, accounting for more than 60% of all dementia patients. The illness affects more than 4.5 million older Americans (some estimates are as high as 5.1 million). One in 10 people over the age of 65 is likely to develop Alzheimer disease. The prevalence is expected to increase over the next few decades, as the population ages.
Alzheimer disease likely has more than one cause. Some of these appear to be inherited (such as the inheritance of the apolipoprotein E [APOE] gene), although genetics alone does not account for all cases of the disease. The final pathway leading to brain cell injury in Alzheimer disease is the excessive build up of abnormal proteins (called amyloid beta and tau) deposit in neurons, which produce amyloid plaques, gliosis, and neurofibrillary tangles visible on microscopic examination of brain tissue. Neuronal loss eventually occurs.
SYMPTOMS AND SIGNS
The disease begins with a mild memory loss (Stage I), which then progresses to deterioration of intellectual functions, personality changes, and speech and language problems (Stage II). In the terminal stage (Stage III), patients depend on others for activities of daily living. Seizures, hallucinations, delusions, paranoia, or depression can occur in either Stage II or III. Persons with Alzheimer disease will eventually develop macular degeneration SEE TABLE: Stages of Alzheimer Disease
The diagnosis is usually made on clinical grounds, by ruling out other causes of cognitive dysfunction. A definitive diagnosis is made during brain biopsy (which is very rarely performed), or after death, during autopsy.
Characteristic pathophysiological changes in the brain include neuritic plaques, neurofibrillary tangles, and marked cerebral atrophy. In addition to structural changes, abnormalities in cranial neurotransmitters may occur. Acetylcholine, for example, may be reduced by as much as 75%, contributing to cognitive impairment.
The treatment of Alzheimer disease includes environmental structuring and drug therapy. Environmental structuring means provision of a safe, stimulating milieu that offers consistency and comfort for the patient. Drug therapy is to improve memory rather than cure the disease. Several cholinergic drugs, e.g., donepezil HCl (Aricept), or memantine are used to slow the decline in cognitive function. Antidepressants and psychotropic medications are used to treat patients who have secondary diagnoses such as depression and hallucinations.
Reality orientation is helpful for patients in early stages of the disease. Validation therapy is most appropriate for patients in Stage II or III.
In collaboration with the physical and occupational therapists, the nurse assesses the patient's need for assistance with activities of daily living. Self-care, exercise, and other activities are encouraged as much as possible. If sleep disturbances occur, the patient should rest between daytime activities, but sleeping during daytime hours is to be discouraged. Neurological function, including mental and emotional states and motor capabilities, is monitored for further deterioration. Vital signs and respiratory status are assessed for pneumonia and other infections. The patient is evaluated for gastrointestinal or urinary problems (anorexia, dysphagia, and urinary or fecal incontinence); fluid and food intake is monitored to detect imbalances. The nurse or assistive nursing personnel takes the patient to the bathroom or bedside commode before and after meals and every 2 hr in between. Skin is inspected for evidence of trauma. The occupational therapist, home health nurse, or case manager assesses the patient's living environment to eliminate hazards and teaches the family to monitor the patient's activity to prevent falls, burns, and other injuries. Expectations should not exceed the patient's ability to perform tasks. Because the patient may misperceive the environment, health professionals should speak softly and calmly and allow sufficient time for answers because of the patient's slowed thought processes and impaired ability to speak. The case manager or nurse evaluates the caregiver's ability to manage the patient at home and makes the appropriate referrals to available local resources such as counseling, support groups, and respite care.
Loneliness, helplessness, and boredom, all associated with institutionalization, can be reduced by incorporating into the environment plants, pets, aviaries, and children as well as opportunities to handle objects having different tactile surfaces. A decor similar to the patient's familiar surroundings may provide comfort. Music therapy may enhance emotional and physical well-being, cognitive skills, ability to communicate, and social functioning. Activity therapy should include the patient’s known earlier interests and preferences. Such activities benefit the patient by encouraging interaction with others and by providing intellectual stimulation.
If mild cognitive impairment or early stage Alzheimer disease is suspected, the person should be evaluated by his physician or referred to a neurologist or gerontologist for evaluation. Early diagnosis allows family members to plan and prepare for the future. The physical and emotional health of the primary caregiver is an additional concern for the health team. Support groups can be a great help to family members by discussing care issues and exchanging information and by considering the caregivers’ feelings and coping skills in an accepting atmosphere. Caregivers experience grief and loss during and after the illness and need help in expressing their grief and pain. Some male caregivers may face unique challenges in taking over many of the tasks traditionally done by an ill wife or mother. All caregivers share the struggle with the common elements of acceptance: accepting the diagnosis, the devastating changes, the limited understanding of others, the progression of the disease, and the need for placement in a nursing home if this becomes necessary. Support groups can help with this process. Respite care can give life-sustaining relief to both partners. Friends who want to help may not even know what to offer, and caregivers must learn how to ask for help with specific tasks.
The local chapter of the Alzheimer's Disease and Related Disorders Association (ADRDA), sometimes simply referred to as the Alzheimer's Association, is an excellent resource. A list of local chapters can be found through the national ADRDA at 919 N. Michigan Avenue, Suite 1000, Chicago, IL 60611-1676 or at their website at www.alz.org.
Alzheimer disease that occurs before the age of 65.
ABBR: LOAD Alzheimer disease occurring after the age of 65. It is the most common form of the disease
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